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Question 1 of 15
What is your best email?
Question 2 of 15
What is your cell phone number?
Question 3 of 15
Please enter your Full Name
Question 4 of 15
How did you hear about us?
Amazon (#1 Best Seller Winning Wellness Method)
Question 5 of 15
If someone referred you to Winning Wellness & Physical Therapy, please state the name of the person or clinic. Please put "N/A" if no one referred you.
Question 6 of 15
What’s the primary reason for wanting to speak to a specialized Registered Dietitian?
Question 7 of 15
What is your main problem or concern?
Question 8 of 15
How long have you struggled with this?
Haven’t- This is prevention (not cure)
Too long (years)
Question 9 of 15
What’s your greatest worry about your current situation?
Question 10 of 15
What are your current goals?
Question 11 of 15
How committed are you to achieving those goals?
A little committed
Question 12 of 15
Where would you want your health and weight to be in the next 6 to 12 months?
Question 13 of 15
Who Do You Prefer To Work With As Your Nutrition Coach?
Question 14 of 15
What made you apply today of all days? Is there anything else that we should know?
Question 15 of 15
I understand that in order for me to get results I must take action and COMMIT to the process. I understand that this is a SUCCESSFUL process, but a process nonetheless.
Yes, I understand.
No, I am not willing to commit.